What are the alternatives?

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1 Aesthetic Extender Symposium 2013 Laser Hair Removal David Ciocon, MD Staff Associate, Skin Laser & Surgery Specialists of NY & NJ Director of Procedural Dermatology & Dermatologic Surgery Director of Clinical Operations, Division of Dermatology Assistant Professor of Medicine Montefiore Medical Center, Albert Einstein College of Medicine What are the alternatives? Waxing Plucking/tweezing Chemical depilatories Shaving Threading Electrolysis Permanent hair removal Doing Nothing How do I approach the laser consult? Today s patient is better educated Review the entire procedure Manage their expectations Counsel on possible outcomes Describing the procedure. Hair anywhere on the body can be treated. The laser targets color (melanin), and black and brown hairs respond best. Coarser hairs respond better. Finer hair, even if dark, respond less. White, gray, blonde, and light red hairs do not respond very well. With each treatment, hairs become fewer, lighter and thinner

2 Stages of Hair Growth Does it hurt? Hair best treated in the ANAGEN Phase. Not all hair follicles contain hair growing at the same time Laser hair removal can only treat follicles that have hair in them. Expect 70%-90% reduction in hair after 6 treatments (4 weeks apart) Should not be painful. Most people say it feels like a snap of a rubber band. Any pain more than level 4/10 requires reevaluation. Permanent Hair Reduction long-term stable reduction in the number of hairs re-growing after a treatment regime The FDA allows this definition Do results vary? Yes. 3 main reasons Skin Color Light skin vs dark skin Hair Color Black hair vs blonde hair Hair Type - Coarse hair vs fine hair Other factors- age, sex, genetics, heredity, hormonal changes Therefore RESULTS CANNOT BE GUARANTEED

3 What are the risks? Burns or blisters Dyspigmentation Scars Paradoxical hypertrichosis Preparing for Treatment Shave the areas to be treated on the day of or 1 day prior to treatment Avoid sun at least 2 weeks before No waxing, plucking, threading or tweezing 4 weeks before Chemical depilatory one week before Preventing Complications 2 things you can tell your patients 1. Recommend no tanning Avoid tanning 2 weeks before and 2 weeks after the treatment 2. BE sensitive to pain level during the treatment. Selective photothermolysis Laser Hair Removal Targets the pigment in the hair follicle. Heat is absorbed and destroys the cells lining the hair follicle specifically around the bulb, bulge, and vascular supply.

4 Patient Consult What are the 3 cycles of hair growth? Anagen: Hair is actively growing Catagen: Hair is dormant Telagen: Hair is falling out Hair Anatomy Hair Biology Follicle Vascular Supply (matrix) Epidermis Sebaceous Gland Bulge Bulb Anagen Catagen Telogen Bulb / bulge are critical structures responsible for hair re-growth

5 Laser Hair Removal Which lasers can be used? Unwanted hair With laser treatment Hair shaft and follicles are disabled Long pulse Ruby (694 nm) Long pulse Alexandrite (755 nm) Long pulse Diode (810 nm) Long pulse ND-Yag (1064 nm)* Intense pulsed light ( nm) *Best for darker skin types Hair Growth Information Body Area % Anagen Hair % Telogen Hair Telogen Duration Follicles density/cm2 Depth of follicle Axillae 30% 70% 3 months mm Brow and Ears 10-15% 85-90% 3 months mm Beard 70% 30% 10 weeks mm Upper Lip 65% 35% 6 weeks mm Scalp 80-90% 13% 3-4 months mm Trunk 10-20% 80-90% 4 months mm Pubic Area 20-30% 70% 3 months mm Arms 20% 80% 18 weeks mm Legs & Thighs 20% 80% 6 months mm Breast 30% 70% 3 months mm Over 1300 nm penetration decreases due to absorption of light by water Most penetrating is red and near IR at nm Longer wavelengths minimize absorption by epidermal melanin

6 DCD -Cryogen spray milliseconds before laser pulse -Cools /protects epidermis from thermal damage -Protects darker skin types -Good visibility / does not slow treatment -No messy gels Treatment Protocol For Hair Removal Post Treatment Aloe vera Topical steroids Topical antibiotics for folliculitis prone areas Sunblock of SPF 30 if treated area is exposed to the sun Eflornithinecream Avoid sun for AT LEAST two weeks Dynamic Cooling Fitzpatrick Skin Types -Short spray of cryogen onto skin milliseconds before laser pulse -Rapid, efficient cooling of epidermal layers only -Does not cool subsurface targeted structures -Does not impede visibility or treatment speed Skin Type Typical Skin Type Definition Skin Reaction on over exposure to UV light Red-blonde Hair Blue-green Eyes Very light Skin Light to Medium Hair Light to Medium Eyes Light to Medium Skin Medium Hair Medium to Dark Eyes Medium to Olive Skin Dark Hair Dark Eyes Dark Olive to Brown Skin Dark Hair Dark Eyes Dark Skin Dark Hair Dark Eyes Very Dark Skin Always Burns Never Tans Usually Burns Seldom Tans Moderate Burns Usually Tans Burns Mildly Moderate Browning Seldom Burns Deep Browning Does Not Burn No Change in Color

7 Treatment of dark skin types Long wavelengths or wavelength ranges Long pulse durations Large spot sizes (lower fluences) Cooling Treatment Pearls Start at minimum fluence needed to see clinical endpoint: peri-follicular erythema/edema With each treatment, 4 to 6 weeks apart, hairs become lighter and thinner Gradually increase fluence and decrease pulse duration Dark, coarse hairs (lower fluences, longer pulse duration) Lighter, fine hairs (higher fluences, shorter pulse durations) Treatment Pearls Fluence relates to hair color Pulse duration relates to hair width/texture Frequency Higher the frequency, the less time to cool between pulses Cooling (DCD) Cooling intervals must be adjusted based on skin type Excessive cryogen can cause hypopigmentation Treatment Pearls Holding the laser handpiece FLUSH PERPENDICULAR NO MORE THAN 30% OVERLAP

8 Treatment Pearls Cooling Ice packs Dynamic cooling Cold roller Cold gel Chilled laser tips Diode Nd-YAG IPL (sapphire window) Zimmer cooling Comparative study of 4 lasers 10 subjects underwent laser hair removal on back & thighs Skin types I- III Ages years Treated twice with: Intense pulsed light with red filter ( nm) Intense pulsed light with yellow filter ( nm) 810 nm diode 755 nm alexandrite laser Amin SP, Goldberg DJ. Clinical comparison of four hair removal lasers and light sources. J Cosmet Laser Ther. 2006;8(2):65-8. Recent innovations Home laser devices Pneumatic compression handpieces Suctions skin into contact with treatment tip Blanches out blood vessels Minimizes pain Comparative study of 4 lasers 4 treatment areas Non-treated areas compared to marked treated areas Hair count camera 1, 3, & 6 months, after second treatment Amin SP, Goldberg DJ. Clinical comparison of four hair removal lasers and light sources. J Cosmet Laser Ther. 2006;8(2):65-8.

9 Results: Photographs revealed significant decrease in hair counts (-50%) No statistical difference in efficacy between the four different light devices Side effects minimal Cryogen spray-based alexandrite laser showed highest pain scores Contraindications History of gold intake - chrysiasis Pregnancy No clear contra-indication Consider the following Liability Hormonal changes Amin SP, Goldberg DJ. Clinical comparison of four hair removal lasers and light sources. J Cosmet Laser Ther. 2006;8(2):65-8. Contraindications Accutane Most physicians recommend that patients should cease usage for at least 6 months. Sun exposure Tanning is an absolute contraindication AVOID the Sun for at least 2 weeks prior to a treatment and 2 weeks after. The chances of pigment changes and other minor skin irritations are high. This included tanning sprays and lotions. Remember pigment is pigment Contraindications What about tattoos? Tattoos and permanent make-up should be avoided Can be source of liability Areas with permanent make-up should be covered or avoided

10 F.A.Q. Can patients use sunless tanning products? No. Patient Consult Photo-Document It is important to take pictures of the area to be treated. Patients will sometimes forget what they looked like at the starting point. F.A.Q. What about braces or other dental work? - Yes. Frequently gauze is placed between the cheek and gum for those patients who experience a tingling sensation on their teeth. Complications There are risks and complications that can occur from laser treatment. Use of conservative DCD settings are important. Complications are rare! Heat rash Bruising Scarring Infection Hyper-pigmentation Hypo-pigmentation Swelling Welting/Hives Hypehidrosis 1064 nm ND:YAG

11 Paradoxical hypertrichosis More common in women of Mediterranean descent Fitzpatrick type 3-4 Associated with history of PCOS (polycystic ovarian syndrome) Rx solutions Increase fluence Cold packs Two passes at lower fluence (Alexandrite) Spironolactone Laser Hair Removal Used by Permission of Syneron, Courtesy of Charlotte Kaae Westerled Post 1 Month Test Spots When skin reaction is a concern, always perform a test spot at a couple of different, lower fluences in an inconspicuous site. Untoward skin responses may occur if there is sun exposure within 1-2 days of treatment. Laser Hair Removal Used by Permission of Syneron, Courtesy of Sharyn Laughlin, M.D. Six Months Post 5 Treatments

12 Laser Hair Removal Laser Hair Removal Used by Permission of Syneron, Courtesy of James Shaoul, M.D. Post 2 Treatments Laser Hair Removal Laser Hair Removal Used by Permission of Syneron, Courtesy of James Shaoul, M.D. Six Months Post 4 Treatments

13 Laser Hair Removal Thank You! Used by Permission of Syneron, Courtesy of Dr Shaoul, M.D. Post 2 Treatments References Goldberg, DJ. Laser Hair Removal. New York: Taylor & Francis, Tierney EP, Goldberg DJ. J Cosmet Laser Ther. 2008; 10(1): Gan SD, Graber EM. Laser Hair Removal. Dermatol Surg. 2013;39(6):